The patient must have no prescription coverage for the requested medication and meet income guidelines that are not disclosed. It is important that the address on the prescription matches the mailing address on the application. If this is not the case, please attach letterhead to verify the delivery address. If the patient does not enroll in Medicare Part D, then s/he still may eligible for the assistance program.

Who Can Apply

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Anyone requesting assistance can call to request a faxed application or download it from the website.

Required

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The doctor must fill out a section, sign the application and attach a prescription.The patient must fill out a section and sign the application.

Supply

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Up to a 90-day supply

Ship To

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Doctor's office

Note

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A new application is needed for each refill.

Includes Support for This Drug NOTE: Linked drugs are available for Prescribers to Apply Online now.Click drug logo or drug name to start online application.

Aerobid-M Inhaler

Printable Application Forms Applications that patients can fill out and bring to their doctor.